Untreated Hepatitis Research Articles

A Case of Recurrent Idiopathic Hypertrophic Pachymeningitis After Years of Quiescence

Objective To report a case of idiopathic hypertrophic pachymeningitis with recurrence in a new region of the brain after years of quiescence. Background Idiopathic hypertrophic pachymeningitis (IHP) is a rare condition defined by thickening of the dural layer secondary to inflammation without discernible cause. Common symptoms include headache, cranial neuropathies, visual loss, mastoiditis and hearing loss. We present a case of a woman with two discrete episodes of headache and vision changes associated with dural thickening and parenchymal edema in separate locations, eventually with biopsy-supported diagnosis of IHP. A 41-year-old woman presented to our hospital with days of persistent temporal headache, blurred vision and confusion. MRI of the brain with contrast demonstrated left temporal lobe edema and overlying dural thickening, initially concerning for mastoiditis versus malignancy. Bloodwork revealed mildly elevated CRP and chronic untreated hepatitis C (HCV). Lumbar puncture was unrevealing, including cell counts, flow cytometry, cytology, cultures, CSF RPR and herpes simplex. Additional infectious workup, including for tuberculosis and fungi, was negative. IgG4 levels were normal, and ANCA screening was negative. CT of the chest revealed lung and liver nodules with non-specific inflammation on biopsy. Mastoidectomy with myringotomy showed no infection. PET scan was unremarkable. Ultimately, biopsy of dural thickening showed chronic inflammation, predominantly CD-163+ histiocytes without granulomas or malignancy. Seven years prior, the patient suffered a similar episode, with MRI showing extensive bilateral frontal dural thickening with associated edema. Symptoms resolved after course of corticosteroids with taper, though minor right frontopolar gliosis persisted. IHP suspected after similar workup, but no biopsy performed. Design/Methods NA. Results NA. Conclusions IHP is clinically well-described, but data on course and recurrence patterns over time is scarce. This case demonstrates that recurrence is not restricted to original affected areas and can happen after years of quiescence. Given course and positive HCV, further longitudinal follow-up and studies are warranted.

ODP093 Hunt for Hypercalcemia

Abstract Hypercalcemia is a relatively common clinical problem. Among all causes of hypercalcemia, primary hyperparathyroidism and malignancy are the most common. This case highlights the importance of collaboration between subspecialists to identify the etiology of a patient's hypercalcemia. A 71-year-old male with history of tobacco use and untreated hepatitis C, presented to the emergency department with several weeks of progressively painful, non-traumatic right upper extremity (RUE) swelling. Chest CT showed a 1.4 cm right axillary lymph node and the patient was referred to general surgery for a biopsy which was deferred due to size. Due to worsening lymphedema, the patient underwent a venogram with plans for a lymphedema pump, however in the interim he presented with worsening RUE edema. Labs were notable for Ca 12.7 mg/dL(8.6-10.3) though the patient reported taking chlorthalidone and calcium-based antacids. The patient was admitted with lymphedema progression and new-onset hypercalcemia. Labs were significant for suppressed PTH 6.8 pg/ml(10-66), undetectable PTHrP, Vit D 9.9 ng/mL(32-100), 1,25-Vit D 110 pg/mL(19.9-79.3), and SPEP/UPEP without an M-spike. Additional labs included PSA 17.96 ng/mL(0-3.9) and LDH 3471 units/L(94-260). Chest CT demonstrated a few sub-centimeter calcified pulmonary nodules with the appearance of chronic granulomas, but no evidence of hilar or mediastinal lymphadenopathy, significantly reducing the likelihood of sarcoidosis. RUE CT showed cortical destruction of the humeral head and proximal shaft, along with infiltrative enlargement of the muscles. There were also a few enlarged axillary lymph nodes, the largest measuring 2 cm. The patient was hydrated with initial improvement of his labs however calcium subsequently increased to 13.5 mg/dL. Due to concern for 1,25-Vit D mediated hypercalcemia and the source still unknown, the patient was started on prednisone 20 mg with normalization of the calcium level. An excisional lymph node biopsy followed by flow cytometry confirmed the diagnosis of diffuse large B cell lymphoma(DLBCL). The patient was treated with chemotherapy and had since been in remission. Of note the patient was also found to have localized prostate cancer treated with external beam radiation . Hypercalcemia is estimated to occur in approximately 30% of patients with malignancy and is associated with a poorer prognosis. Mechanisms include humoral hypercalcemia (PTHrP), osteolytic cytokine production, extensive bone metastasis in the absence of excess osteolytic factors, and production of 1,25-Vit D. Our patient had several risk factors for hypercalcemia including thiazide and antacid use, which may cause milk-alklai syndrome; an elevated PSA, which was eventually confirmed to be prostate cancer; and an elevated 1,25-Vit D of unknown etiology. Due to the risks associated with hypercalcemia and after extensive conversations amongst the subspecialists, the decision was made to start empiric treatment with prednisone. Eventually the patient underwent CT guided biopsy confirming the diagnosis of DLBCL, but it was a "hunt". Presentation: No date and time listed

Early Treatment of Hepatitis C Virus Improves Health Outcomes and Yields Cost-Savings: A Modeling Study in Argentina

OBJECTIVE: Most untreated hepatitis C virus (HCV) patients develop chronic infection and severe complications, including death. Direct-acting antivirals in early stages of liver fibrosis reduce complications and healthcare costs. However, therapy is often delayed, and patients in early stages have limited access to effective treatments. We assessed the clinical and economic effect of treating chronic HCV at early versus late stages of disease in Argentina. 
 
 METHODS: A Markov model of the natural HCV history was used to forecast lifetime liver-related and economic outcomes from social security sector perspective. Healthcare use and transition probabilities were drawn from literature. Demographic characteristics of the patients and treatment attributes were based on data from registrational trials of glecaprevir/pibrentasvir. 
 
 RESULTS: Lower rates of all hepatic complications and liver-related mortality were predicted when treatment was initiated in mild versus advanced disease. Sustained virologic response rates were similar among all stages. Higher quality-adjusted life years (QALYs) were predicted when treatment was initiated in mild (F0-F1) versus moderate (F2-F3) or advanced (F4) liver disease (11.5, 9.9, and 7.5 QALYs, respectively). Delaying treatment increased long-term total lifetime costs (F4: AR$ 1 437 816; F2-F3: AR$ 967 673; F0-F1: AR$ 954 018; 37.10 AR$=1 USD, Nov 2018 exchange rate) and provided fewer QALYs. 
 
 CONCLUSIONS: Our study show early treatment was a dominant strategy compared with treatment in advanced stages of liver disease. These results may help health policy makers take actions to reduce health and economic burden of HCV in Argentina.

S1332 Assessment of Risk Factors of Hepatic Steatosis Diagnosed by Vibration Controlled Transient Elastography (VCTE) in Chronic Hepatitis C Virus Infected Patients

Introduction: In chronic hepatitis C patients, the prevalence of steatosis ranges from 40% to 86%. Our aim was to study the risk factors of moderate/severe hepatic steatosis diagnosed by vibration-controlled transient elastography (VCTE) in these patients. Methods: This retrospective cross-sectional study included a cohort of 158 adult patients with suspected nonalcoholic fatty liver disease (NAFLD) evaluated in the clinic. Patients with significant alcohol consumption, oral contraceptive use, hepatitis B, autoimmune hepatitis, and primary biliary cirrhosis were excluded. Steatosis was categorized as S0-S1 (mild) and S2-S3 (moderate/severe) based on the controlled attenuation parameter (CAP) grade. Continuous variables were assessed using an unpaired t-test and categorical variables using chi-Square with p< 0.05 were considered statistically significant. A multinominal logistic regression analysis was done to study the relationship between the CAP grade (dependent variable) and significant covariates (independent variables) while controlling for the effect of each other. The model fitting criteria used was -2 log-likelihood (LL) which was tested for goodness-of-fit and pseudo R2 showed a Negelkerke value of 0.520. Results: 136 patients met inclusion criteria. A moderate/severe steatosis score was associated with various risk factors: obesity (p< 0.05), DM (p< 0.014), metformin use (p< 0.0017), fibrosis (p< 0.009). A 4x2 chi-square Table showed 40% of patients with hepatitis C, 68% with hepatitis C + DM, 68% with DM, and 61% non-hepatitis C, non-DM patients (p-0.028) had moderate to severe hepatic steatosis. On regression analysis, the -2 LL of the reduced model in patients with hepatitis C and hepatitis C + DM revealed that omitting the effect of obesity resulted in zero degrees of freedom (df 0). Obesity had a significant association with steatosis (chi-square value 52, df 12). DM had a weak association with steatosis (chi-square value 0.825, df 3). (Figure) Conclusion: Hepatic steatosis is independently associated with metabolic parameters like obesity and DM. The chi-square analysis initially indicated that hepatitis C is associated with steatosis, but using multivariate analysis, we accounted for potential confounders, i.e., the most significant risk factor for steatosis in untreated hepatitis C patients is their BMI. Thus, the management of obesity in patients with chronic hepatitis C may be necessary for reducing the risk of steatosis progression and improving their fibrosis score.Figure 1.: Results of patient characteristics and multivariate regression analysis

S2145 The Great Imitator Hiding in Plain Sight

Introduction: Lower gastrointestinal syphilis is a rare manifestation of early syphilis transmitted through anal contact. It usually occurs in men and transwomen who have sex with men. It can present with symptoms of proctitis including hematochezia, mucous discharge, and tenesmus, and can mimic inflammatory bowel disease (IBD). We present a case of intestinal syphilis in an HIV patient who presented with fevers and bloody diarrhea found to have intestinal spirochetosis. This case report adds to the importance of including STI colitis in the differential when presented with high-risk patients with lower gastrointestinal features. Case Description/Methods: A 32-year-old male with a history of untreated HIV, untreated hepatitis C, and IV drug use presented to the emergency department with a one-month history of worsening sharp and diffuse abdominal pain, subjective fevers, and blood-tinged mucoid bowel movements. He was diagnosed with rectal gonorrhea and chlamydia infection a few days prior to presentation and was treated with intramuscular ceftriaxone. He was discharged on doxycycline, which he failed to take. The patient’s social history is significant for being a sex worker and having sex with males. On physical exam, he was cachectic appearing with a diffusely tender abdomen. A rectal exam revealed palpable nodules and anal condylomas. He was treated with HAART and doxycycline for a presumed lymphogranuloma venereum infection. Computed Tomography (CT) of the abdomen pelvis showed an irregular and thick-walled rectum with perirectal soft-tissue stranding and necrotic nodes in the left perirectal region, the largest measuring 1.7 x 1.7 cm. Given continuous bloody bowel movements and a family history of colorectal cancer, a colonoscopy was obtained and showed scattered and patchy severe edema, erythema, and friability with shallow and deep rectal ulcerations. His labs revealed late latent syphilis infection (1:128 titer) and he was started on penicillin (PCN). Pathology of the colon later revealed intestinal syphilis as depicted in the Figure. Discussion: In recent years, there has been an increase in the number of reported cases of syphilis, especially in men and transwomen who have sex with men. Given this rare manifestation of syphilis, it is important to recognize and effectively treat to reduce patient morbidity and minimize community spread. Our case demonstrated the importance of maintaining a high level of suspicion for high-risk individuals presenting with lower gastrointestinal symptoms.Figure 1.: Right colon (Specimen A), left colon (Specimen B), and rectum (Specimen C).

STUDY OF THE EFFECT OF CRYOPRESERVED PLACENTA EXTRACT ON THE PROCESSES OF CYTOLYSIS AND LIPID PEROXIDATION IN CCL4-INDUCED LIVER DAMAGE

Abstract. The search for new strategies for the correction of exogenous toxic liver lesions is due to the steady increase in the incidence of hepatitis and cirrhosis among the working population, which is an important medical and social problem.&#x0D; The aim is to determine the effect of cryopreserved placenta extract (CEP) on the state of the liver of rats with tetrachloromethane (CCl4)-induced damage by indicators of lipid peroxidation (LP) and markers of cytolysis.&#x0D; Materials and methods. Experimental studies were conducted on 28 male rats. Acute CCl4-induced hepatitis was reproduced by a single injection of 50.0% CCl4 oil solution. KEP was administered 1 time per day for 5 days before the introduction of CCl4. The material for the study was whole blood and liver homogenates, in which the content of reactants with thiobarbituric acid (TBA-RP), catalase activity, superoxide dismutase (SOD) activity, alanine aminotransferase (AlAt) and aspartate aminotransferase (AsAt) activity, as well as γ-glutamyl activity were determined. γ-glutamyl transpeptidases (γ-GTP) and alkaline phosphatase (AP) according to standard methods.&#x0D; Results and discussion. The study showed that the content of TBA-RP in liver homogenates was lower (p&lt;0.01) by 35.6% in rats that were prophylactically injected with CEP compared to rats with simulated CCl4-induced hepatitis without treatment (control group). An increase in the level of catalase (p=0.02) with the use of CEP was established by 33.8% and an increase in the activity of SOD (p&lt;0.01) by 45.5% compared to the indicators of rats in the control group. It is also shown that the level of AlAt after administration of CEP decreased (p&lt;0.001) by 56.0%, the level of AsAt decreased (p&lt;0.001) by 48.6%, the level of γ-HTP decreased by 37.8% compared to the rats with untreated CCl4-induced hepatitis.&#x0D; Conclusions. Prophylactic five-day administration of CEP leads to the leveling of CCl4-induced LP activation and signs of cytolysis syndrome.

Comparison of the characteristics of patients treated with sublingual vs. long-acting injectable buprenorphine formulations for treatment of opioid use disorder: A retrospective cohort study.

Long-acting injectable buprenorphine (LAI-BPN) was introduced in recent years as a novel treatment for opioid use disorder. Despite growing evidence-base of its effectiveness, there is limited research on the relationship between this treatment and patient characteristics. This descriptive, retrospective cohort study compared sociodemographic and clinical variables between patients treated with SL-BPN and those treated with LAI-BPN at a large metropolitan health service in Queensland, Australia. Patients that transitioned to LAI-BPN were more likely to be single, have a comorbid mental illness, untreated hepatitis C infection and longer duration of unsanctioned opioid use. Patients continuing treatment with SL-BPN were more likely to fail to attend appointments and have urine drug screen results positive for gabapentinoids. The results of this study contribute to currently limited literature on this novel treatment option in an Australian context, highlighting factors which may influence patient and prescriber treatment choices. Clinicians may be more inclined to prescribe LAI-BPN to patients with higher psychosocial comorbidity to facilitate engagement in treatment.

Care Navigation Increases Initiation of Hepatitis C Treatment After Release From Prison in a Prospective Randomized Controlled Trial: The C-LINK Study.

BackgroundPrison-based hepatitis C treatment is safe and effective; however, many individuals are released untreated due to time or resource constraints. On community re-entry, individuals face a number of immediate competing priorities, and in this context, linkage to hepatitis C care is low. Interventions targeted at improving healthcare continuity after prison release have yielded positive outcomes for other health diagnoses; however, data regarding hepatitis C transitional care are limited.MethodsWe conducted a prospective randomized controlled trial comparing a hepatitis C care navigator intervention with standard of care for individuals released from prison with untreated hepatitis C infection. The primary outcome was prescription of hepatitis C direct-acting antivirals (DAA) within 6 months of release.ResultsForty-six participants were randomized. The median age was 36 years and 59% were male. Ninety percent (n = 36 of 40) had injected drugs within 6 months before incarceration. Twenty-two were randomized to care navigation and 24 were randomized to standard of care. Individuals randomized to the intervention were more likely to commence hepatitis C DAAs within 6 months of release (73%, n = 16 of 22 vs 33% n = 8 of 24, P < .01), and the median time between re-entry and DAA prescription was significantly shorter (21 days [interquartile range {IQR}, 11–42] vs 82 days [IQR, 44–99], P = .049).ConclusionsCare navigation increased hepatitis C treatment uptake among untreated individuals released from prison. Public policy should support similar models of care to promote treatment in this high-risk population. Such an approach will help achieve hepatitis C elimination as a public health threat.

Peripartum Severe COVID-19 Pneumonia: Fetal and Neonatal Implications.

Peripartum Severe COVID-19 Pneumonia: Fetal and Neonatal Implications.

Retrospective multicentre study on the effectiveness of first-line direct-acting antivirals against hepatitis C virus genotype-1.

What is known and objectiveIn Japan, ledipasvir/sofosbuvir, elbasvir/grazoprevir and glecaprevir/pibrentasvir are recommended as first‐line treatments for patients with untreated hepatitis C virus genotype 1. Although they have demonstrated a high efficacy in clinical trials, there are no direct comparative studies. Clarification of their effectiveness and safety in real‐world clinical practice is required. Therefore, we conducted a retrospective multicentre study on the effectiveness of these direct‐acting antivirals in real‐world clinical practice.MethodsWe retrospectively evaluated the clinical data of untreated patients with persistent HCV genotype 1 infection who started first‐line treatment with ledipasvir/sofosbuvir, elbasvir/grazoprevir or glecaprevir/pibrentasvir between September 2015 and January 2019 at 11 medical institutions in Japan. The primary efficacy endpoint was a sustained virologic response after 12 weeks of treatment. The secondary endpoints included sustained virologic response after 24 weeks of treatment and end of treatment response. The safety endpoint was treatment completion rate.Results and discussionDuring the study, 420 patients (median age, 70 years; 181 males) received ledipasvir/sofosbuvir, 48 (median age 72, years; 29 males) received elbasvir/grazoprevir and 63 (median age 66, years; 35 males) received glecaprevir/pibrentasvir. For ledipasvir/sofosbuvir, elbasvir/grazoprevir and glecaprevir/pibrentasvir, the sustained virologic response after 12 weeks of treatment was 98.6%, 97.9% and 100%; the sustained virologic response after 24 weeks of treatment was 99.0%, 97.7% and 100%; the end of treatment response was 99.8%, 97.9% and 98.4%; and the treatment completion rate was 98.3%, 91.7% and 100% respectively.What is new and conclusionIn real‐world clinical practice, hepatitis C virus treatment with ledipasvir/sofosbuvir, elbasvir/grazoprevir and glecaprevir/pibrentasvir was effective with safety.

B-cell activating factor and IL-21 levels predict treatment response in autoimmune hepatitis

Background & AimsIncreased serum IgG and autoantibodies suggest involvement of B cells in autoimmune hepatitis (AIH). The aim of this study was to assess levels of B cell activating factor of the tumour necrosis family (BAFF), IL-21, and circulating B cell populations in AIH and correlate these to treatment response.MethodsBAFF and IL-21 levels were determined in 66 patients with AIH before treatment and 10 healthy controls. Flow cytometry was performed on circulating B cells of 10 patients with AIH and 12 healthy controls.ResultsBased on BAFF and IL-21 levels, untreated patients with AIH were divided into 3 groups: 27 (41%) patients with normal BAFF and IL-21 (normal BAFF), 27 (41%) patients with elevated BAFF but normal IL-21 (high BAFF), and 12 (18%) patients with elevated IL-21 (high IL-21). The high BAFF group presented with higher bilirubin compared with the normal BAFF and high IL-21 groups (159 vs. 26 vs. 89 μmol/L; p = 0.001; Mann–Whitney U test). After 12 months of treatment, 54% of the high BAFF group reached remission compared with 34% of the normal BAFF group and 0% of the high IL-21 group (p = 0.006, Chi-square test). During follow-up, 3 patients (25%) with high IL-21 developed primary sclerosing cholangitis (PSC) variant syndrome. Autoimmune-associated B cells were increased in patients with AIH compared with healthy controls (4.4 vs. 1.4%; p = 0.003, Mann–Whitney U test). BAFF levels were correlated positively with naïve B cells (p = 0.01) and negatively with class-switched B cells (p = 0.003) and nonclass-switched B cells (p = 0.005, Spearman correlation).DiscussionUsing BAFF and IL-21, we identified different immunological phenotypes of AIH with a different presentation, treatment response, and outcome. Patients with high IL-21 had the poorest treatment response and a risk of developing PSC variant syndrome. BAFF level was related to shifts in circulating B-cell populations.Lay summaryIn patients with untreated autoimmune hepatitis (AIH), circulating B-cell activating factor of the tumour necrosis family (BAFF), IL-21, and B-cell populations were determined. Three subgroups were identified: with (1) normal BAFF and IL-21, (2) elevated BAFF and normal IL-21, and (3) elevated IL-21. Remission after 1-year treatment occurred in 54, 34, and 0% in Groups 1, 2, and 3, respectively. Group 2 had higher bilirubin, indicating more liver dysfunction. In 25% of patients with high IL-21, AIH-PSC variant syndrome developed, but none in the other groups. Autoimmune-associated B cells were elevated and BAFF levels correlated with certain B cells.

Serum soluble programmed cell death 1 levels predict spontaneous functional cure in inactive carriers with chronic hepatitis B.

Hepatitis B surface antigen (HBsAg) seroclearance is the most important milestone indicating favourable clinical outcomes in patients with chronic hepatitis B (CHB). However, it is difficult to achieve due to the impaired HBV-specific immunity, such as programmed cell death 1 (PD-1)-associated T cell exhaustion. We assessed soluble PD-1 (sPD-1) as a novel seromarker for predicting spontaneous HBsAg loss. Serial serum levels of sPD-1 were evaluated in 1046 untreated hepatitis B e antigen (HBeAg)-seronegative individuals who had achieved undetectable serum HBV DNA. Multiple regression analyses were applied to assess associations among baseline and subsequent sPD-1 levels, HBsAg decline during follow-up, and spontaneous HBsAg seroclearance. A total of 390 individuals achieved spontaneous HBsAg seroclearance during 6464.4 person-years of follow-up. Baseline sPD-1 levels were inversely associated with baseline HBsAg levels (qHBsAg) as well as a greater decline in qHBsAg during follow-up. Incidence rates of HBsAg seroclearance were 11.5, 61.7, 96.7 and 151.0 per 1000 person-years for sPD-1 levels of ≥4000, 536-3999, 125-535 and <125pg/mL, respectively (Ptrend <0.0001). Compared with baseline sPD-1 levels ≥4000pg/mL, the rate ratio (95% CI) of HBsAg seroclearance was 2.1 (1.1-3.9), 3.0 (1.6-5.5) and 5.1 (2.8-9.5), for baseline sPD-1 levels of 536-3999, 125-535 and <125pg/mL, respectively, after adjustment for sex, age and serum alanine aminotransferase and HBsAg levels. sPD-1 level is a novel marker which independently predicts spontaneous HBsAg seroclearance of HBeAg-negative inactive CHB patients with undetectable HBV DNA. (word count: 234, <250).

Complicated Case of Multidrug-Resistant Tuberculosis with Multiple Comorbidities, Successfully Treated After Several Treatment Modifications

A 59-year-old man with relapsed pulmonary TB developed rifampin resistance. He presented with chronic untreated hepatitis B, which developed into liver cirrhosis, type 2 diabetes with diabetic retinopathy, and osteoarthritis of right knee. His initial MDR regimen included levofloxacin, cycloserine, bedaquiline, linezolid, and high-dose isoniazid. He developed episodes of linezolid-induced myelosuppression, resulting in temporary discontinuation and dose reduction, and ultimately, substitution of linezolid. On the seventh month of treatment, he developed severe depression with visual hallucination, resulting in cycloserine dose reduction. We maintained the principle of at least 4 active drugs throughout his treatment. He was considered cured after 26 months of treatment.

Impact of Donor and Recipient Clinical Characteristics and Hepatic Histology on Steatosis/Fibrosis Following Liver Transplantation.

Deceased donor and recipient predictors of posttransplant steatosis/steatohepatitis and fibrosis are not well known. Our aim was to evaluate the prevalence and assess donor and recipient predictors of steatosis, steatohepatitis, and fibrosis in liver transplantation recipients. Using the immune tolerance network A-WISH multicenter study (NCT00135694), donor and recipient demographic and clinical features were collected. Liver biopsies were taken from the donor liver at transplant, and from recipients per protocol and for-cause (ie, abnormal transaminases and to rule out rejection) and were interpreted by a central pathologist. One hundred eighty-three paired donor/recipients liver biopsies at the time of transplant and posttransplant follow-up (median time 582 d; average time to last biopsies was 704 d [SD ± 402 d]) were analyzed. Donor steatosis did not influence recipient steatosis or fibrosis. Ten of 183 recipients had steatohepatitis on the last biopsy. Recipient body mass index at the time of liver biopsy was the most influential factor associated with posttransplant steatosis. Both donor and recipient metabolic syndrome features were not associated with graft steatosis. Untreated hepatitis C viral (HCV) infection was the most influential factor associated with the development of allograft fibrosis. In a large experience evaluating paired donor and recipient characteristics, recipient body mass index at the time of liver biopsy was most significantly associated with posttransplant steatosis. Untreated HCV etiology influenced graft fibrosis. Thus relative to untreated HCV, hepatic fibrosis in those with steatosis/steatohepatitis is less common though long-term follow-up is needed to determine the course of posttransplant fibrosis. Emphasis on recipient weight control is essential.

A Digital Case-Finding Algorithm for Diagnosed but Untreated Hepatitis C: A Tool for Increasing Linkage to Treatment and Cure.

Background and AimsAlthough chronic HCV infection increases mortality, thousands of patients remain diagnosed‐but‐untreated (DBU). We aimed to (1) develop a DBU phenotyping algorithm, (2) use it to facilitate case finding and linkage to care, and (3) identify barriers to successful treatment.Approach and ResultsWe developed a phenotyping algorithm using Java and SQL and applied it to ~2.5 million EPIC electronic medical records (EMRs; data entered January 2003 to December 2017). Approximately 72,000 EMRs contained an HCV International Classification of Diseases code and/or diagnostic test. The algorithm classified 10,614 cases as DBU (HCV‐RNA positive and alive). Its positive and negative predictive values were 88% and 97%, respectively, as determined by manual review of 500 EMRs randomly selected from the ~72,000. Navigators reviewed the charts of 6,187 algorithm‐defined DBUs and they attempted to contact potential treatment candidates by phone. By June 2020, 30% (n = 1,862) had completed an HCV‐related appointment. Outcomes analysis revealed that DBU patients enrolled in our care coordination program were more likely to complete treatment (72% [n = 219] vs. 54% [n = 256]; P < 0.001) and to have a verified sustained virological response (67% vs. 46%; P < 0.001) than other patients. Forty‐eight percent (n = 2,992) of DBU patients could not be reached by phone, which was a major barrier to engagement. Nearly half of these patients had Fibrosis‐4 scores ≥ 2.67, indicating significant fibrosis. Multivariable logistic regression showed that DBUs who could not be contacted were less likely to have private insurance than those who could (18% vs. 50%; P < 0.001).ConclusionsThe digital DBU case‐finding algorithm efficiently identified potential HCV treatment candidates, freeing resources for navigation and coordination. The algorithm is portable and accelerated HCV elimination when incorporated in our comprehensive program.

Cystic angiomatosis of the bone, liver, and spleen

Abstract Introduction/Objective Cystic angiomatosis is a very rare entity characterized by multifocal cystic angiomatous lesions of the skeletal system, occasionally involving visceral organ systems. Clinical presentation and progression are extremely variable. Cases with liver involvement are even rarer, and have been described as invariably fatal. The pathogenesis of this disorder is poorly understood, and no treatments are currently available. Methods/Case Report A 24 year old man with history of polysubstance abuse and untreated hepatitis C presented with acute abdominal pain. Imaging revealed hepatosplenomegaly and multiple liver, spleen, and skeletal lesions. Differential diagnoses included metastatic disease, lymphoma, and infection. Apart from known untreated chronic hepatitis C, all infectious, autoimmune and hypercoagulability work-ups were negative. Biopsies of the liver and iliac bone lesions showed areas of benign-appearing vascular proliferation in a background of fibrosis. The vascular endothelial cells were positive for CD34 and CD31 but negative for D2-40. On follow-up approximately eight months later, the patient was asymptomatic. Results (if a Case Study enter NA) NA Conclusion Liver involvement by cystic angiomatosis is exceedingly rare and has been associated with increased mortality. This case provides an example of a patient with incidentally discovered cystic angiomatosis involving liver, spleen, and bone who remains asymptomatic at follow-up. Additional cases are required to understand the pathophysiology and disease course in this group of patients, and to investigate possible therapeutic targets.

ANGIOVAC USE IN ENDOCARDITIS DURING PREGNANCY: A NOVEL APPROACH FOR RECURRENT DEBULKING OF TRICUSPID INFECTIVE VEGETATIONS IN A 27-YEAR-OLD WOMAN IN HER 22ND AND 26TH WEEKS OF PREGNANCY

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Infective endocarditis (IE) during pregnancy is a rare and life-threatening disease with maternal and fetal mortality rates as high as 33% and 29%, respectively. Intravenous (IV) antibiotics with or without surgical modalities are mainstays of treatment. The use of AngioVac offers a less invasive procedure for the removal of thrombi and emboli in patients with contraindications to surgery. While its use has not yet been reported or approved in pregnancy, we present a case where AngioVac was used for debulking vegetations in a patient with tricuspid endocarditis during pregnancy. CASE PRESENTATION: A 27-year-old G2P1001 woman at 21-weeks-gestation with a history of IV drug use, untreated hepatitis C, and hypertension presented to the hospital with 3 weeks of worsening lower extremity edema, palpable purpura, dyspnea, leukocytosis, and fever. Diagnostic workup revealed methicillin-resistant Staphylococcus aureus bacteremia and transthoracic echocardiography showed severe tricuspid valve regurgitation with two vegetations of 2.4 x 1.2 cm and 1.4 x 0.7 cm. Although she met surgical criteria, she was a poor surgical candidate due to septic shock and multi-organ failure. Despite medical management, her symptoms persisted, and she developed pulmonary septic emboli, hemoptysis, and sacroiliitis. Alternatively, the patient was offered an AngioVac procedure at 22 weeks and subsequently at 26 weeks for decompensation with recurrence of valve vegetations. This allowed for nonoperative treatment of her endocarditis and delivery at 33 weeks via cesarean section for superimposed preeclampsia. Apgar scores were 7 and 8 at 1 and 5 minutes, respectively. Newborn's weight was 2000 grams. DISCUSSION: In IE during pregnancy, surgical management is generally avoided due to maternal/fetal morbidity and mortality. Unfortunately, our patient failed medical therapy and surgery carried an unacceptable risk. Current guidelines do not address IE in pregnancy. This may be due to the low incidence or reporting bias. The use of AngioVac proved beneficial. The debulking of vegetations on two occasions reduced the bacterial inoculum, thereby enhancing antibiotic therapy, gaining time for fetal maturation, and allowing the patient to survive to successful delivery. AngioVac device has been described for the treatment of right-sided endocarditis with vegetations, mainly through case reports in experienced centers, but not in pregnancy. This case carried significant challenges and a multidisciplinary discussion and strategy were key in optimizing patient and fetal outcomes. CONCLUSIONS: AngioVac debulking of IE vegetations is a novel approach and was safely used in our pregnant patient. Multidisciplinary discussion and strategy are imperative in the management of IE during pregnancy. More data is needed to widely establish the use of AngioVac in pregnancy. REFERENCE #1: Luo L, Sun Q, Chen L, Ying D, Wu X, Chen Z. Survival of the fetus during maternal thoracotomy under cardiopulmonary bypass for infective endocarditis. J Obstet Gynaecol Res. 2017 Oct;43(10):1634-1638. REFERENCE #2: Divekar A, Scholz T, and Fernandez J. Novel percutaneous transcatheter intervention for refractory active endocarditis as a bridge to surgery-AngioVac aspiration system. Catheterization and Cardiovascular Interventions. 2013;81:1008–1012. REFERENCE #3: Anitha J, Gurley F, et al. Cardiopulmonary bypass during pregnancy. Ann Thorac Surg 2011;91:1191-1197. DISCLOSURES: No relevant relationships by Vira Ayzenbart, source=Web Response No relevant relationships by Sameh Aziz, source=Web Response No relevant relationships by Fernando Fuentes, source=Web Response No relevant relationships by Heather Fuentes, source=Web Response Consultant relationship with Angiodynamics Please note: 5/2020-present Added 04/26/2021 by Mark Joseph, source=Web Response, value=Consulting fee

S3481 Silent and Deadly: Cholangiocarcinoma

Introduction: Cholangiocarcinoma (CCA) is the most common malignancy of biliary origin. Despite advances in the recognition and treatment of CCA, patient prognosis remains poor. CCA is further sub-classified into intrahepatic CCA (iCCA), perihilar CCA (pCCA) and distal CCA(dCCA). We present a case of pCCA with intrabdominal spread in a patient presenting with abdominal discomfort and weight-loss. Case Description/Methods: A 60-year-old male smoker presented to the emergency department due to one month of intermittent, epigastric abdominal pain. He reported severe colicky pain, associated with nausea and non-bilious, non-bloody emesis. Review of system was notable for anorexia and 20lbs weight-loss. His history was significant for chronic alcohol use disorder and untreated hepatitis C virus. He was hemodynamically stable and appeared cachectic. Epigastric tenderness was present on deep palpation. Initial labs revealed an elevated amylase of 190U/L, and GGT of 237U/L. Total and direct bilirubin were 2.5mg/dL and 0.7mg/dL, respectively. CA19-9, AFP and CEA were negative. Abdominal US revealed a markedly dilated pancreatic duct and a solid, hypoechoic mass within the anterior lobe of the liver. CT demonstrated an irregularly enhancing, lesion measuring 6.3x4.5 centimeters. The lesion appeared to be infiltrative and was encasing the SMA and SMV. CT guided biopsy of the liver mass was obtained. Immunohistochemical staining was CK7+ and CK20+ these findings were highly suggestive of pCCA. Due to intrabdominal spread compromising vasculature the tumor was inoperable, interventional radiology performed transcatheter arterial chemoembolization and radiation. The patient was initiated on chemotherapy with scheduled outpatient follow-up. Discussion: Factors that increase the risk of CCA are excessive alcohol consumption, tobacco smoking and viral infections (hepatitis B & C virus). CT imaging is required for evaluation of tumor spread and histopathological analysis is needed to confirm the diagnosis. Treatment of CCA may include resection, radiation, chemotherapy or transplantation. Due to CCAs lack of response to pharmacological treatment, palliative stenting is often performed for symptomatic relief. Delayed diagnosis of CCA portends a poor prognosis with a median 6-month survival less than 40%. Physicians should focus on improvements in modifiable risk factors, such as cessation of alcohol and tobacco as well as the treatment of HBV & HCV infections. Likewise, treatment outcomes and survival require further attention.Table 1.: Types of Cholangiocarcinoma.

DISTRIBUTION OF ACTIVE HEPATITIS C INFECTED POPULATION BY SEX AND AGE GROUPS IN DISTRICT D.I.KHAN, PAKISTAN

Background: Untreated hepatitis C virus infection is major cause of cirrhosis and hepatocellular carcinoma causing significant morbidity and mortality. Our objectives were to determine distribution of active hepatitis C infected population by sex and age groups in District D.I.Khan, Pakistan.Materials Methods: This cross-sectional study was conducted at District Health Office, D.I.Khan, Pakistan from 25 April 2021 to 12 May 2021. Data was collected for period from 11 February 2017 to 22 April 2021. 1062 active hepatitis C infected cases were selected from population at risk consecutively. Sex (nominal) and age groups (ordinal) were variables. Distribution was analyzed by count, percentage and confidence intervals for proportion for population. Hypotheses for distribution were substantiated by chi-square goodness-of-fit test.Results: Out of 1062 active hepatitis C infected population, 569 (53.58%) were men 493 (46.42%) women, and 51 (4.80%) in age group 0-20 years, 433 (40.77%) in 21-40, 476 (44.82%) in 41-60 102 (9.61%) in 60 years. Our distribution by sex (p.00001) and age groups (p.00001) was different than expected.Conclusion: In our study, active hepatitis C infection was more common in men than women and most common in age group 41-60 years, followed by 21-40, 60 0-20 years. Our observed prevalence of active hepatitis C infection in men was lower than expected in women it was higher than expected. Our observed prevalence of active hepatitis C infection in the four age groups was not similar to expected.

Obturator internus abscess in adults: A broad approach to diagnosis.

A 55-year-old male presented to the emergency department with a 2-week history of atraumatic right hip and groin pain, subjective fevers as well as reduced weight bearing on his right leg. His medical background was significant for active intravenous (IV) drug use (injection via groin) and alcohol abuse, untreated hepatitis C, pericarditis and previous Staphylococcus bacteraemia. The initial examination was significant for tenderness of the right hip on palpation with extreme pain on flexion, abduction and adduction. The patient's abdomen was soft and non-tender and no herniae were identified. Initial blood tests revealed a white cell count of 15 × 109/L and C-reactive protein was 3.4 mg/L. Two sets of blood cultures were done on admission and were negative for microbial growth. Computed tomography (CT) imaging showed an undisplaced fracture through the right superior pubic ramus and oedema in the right obturator internus (Fig. 1).